Gait Video of Pronated Right Foot with Corrective Orthotic Devices

If you check the last post, you will see how pronated Julio's right foot is. He is disabled by severe pain following ankle surgery. The hope is that correcting his pronation will alleviate some or all of his symptoms. You can see how following heel contact the shoes and orthotic devices immediate supinate his foot towards a more normal position. He is in 35 degree Inverted Orthotic Devices.

Now compare to shoes but no orthotic devices in this second video.

Gait Video of Pronated Right Foot

See the pronated right foot. The patient has had lateral ankle surgery and post op the surgeon referred him to me for treatment of the severely pronated foot. Post operative pain is quite severe and the hope is if I can eliminate the pronation there will be less lateral ankle and subtalar joint impingement. You can tell how flat that right arch is, what you can not appreciate is that his heel is in severe valgus position (17 degrees everted). The initial orthotics I made for him were 35 degree Inverted which brought his heel position to 9 degrees everted and the second correction of 50 degrees Inverted with Medical Column Correction and Kirby Skive places him to 6 degrees everted.

     See the second video with shoes on but no orthotic devices.

Foot Bones Anatomy Lesson: See if you can beat my 100% in 12.9 seconds

http://www.purposegames.com/game/foot-and-ankle-quiz/info

Type into search box  "Foot Bones"

Click on game upper left corner called Foot Bones
Click on game second time
Press start when you want to challenge my phenomenal 12.9seconds


Then explore the rest of the web site--looks great!!

When Is Swelling Bad? Answer to an Email

Email sent from Jeff in New Jersey today.

Dear Dr. Blake,

A year ago I fractured the right medial sesamoid bone. I just recently

had an MRI and it says it is completely healed.


Problem is it is still pretty much swollen as when it first was


injured. The orthopedic surgeon referred me to another surgeon

because he is at a loss why swelling is still present. I have been

walking around for a year in home made orthotics and I had to open the

shoes on top to acommodate 2 inserts and a dancer pad. Quite a sight!

Do you have any idea why the forefoot is still swollen even though the


sesamoid is healed ?

Thank you very much.

Jeff

 Plantar Axial xray showing the broken lateral fibular sesamoid, not the one Jeff hurt.

 MRI image of the 2 sesamoids under the big toe. Jeff hurt the one towards the outside, not the one more internal.

Typical Dancer's Pad to float the big toe as mentioned in Jeff's email.

Dear Jeff, Thanks for the question. The biggest question concerns whether the swelling is just excessive, or does it mean something still is wrong? Swelling is a normal part of healing, and healing can continue for months and months after a bone injury is completely healed. The body first heals an injury and then heals it further to make it stronger than it was originally. This can produce normal swelling for 2 to 3 times longer than the time it took to heal the bone in the first place. Ankle sprains are probably the most studied injury. The average ankle sprain takes 6 to 8 weeks to heal, yet the average patient has swelling to deal with for 4 and 1/2 months.

     You, of course, want to assume the swelling is normal, and just hanging around too long for your liking. I am assuming by your description is that you have no pain, just swelling. Pain from swelling alone rarely gets above 2 in a pain scale of 0 to 10.  Please comment on this post and I will respond if any of my assumptions are incorrect. If you have swelling and level 4 or more pain, the MRI is not telling the whole picture. You may want to consider a CT Scan which isolates the bone aspect.

     Before you get too excited, I would follow the KISS rule. What is the most obvious? The most common problem with foot injuries on any type is that they swell too much. Our feet are down all day, you have probably been less active which means the swelling has less ability to move out of your foot, and you have worn tight shoes longer than normal (plus it has been the winter). All this can make our feet collect fluid in general, and we will collect more fluid in an injured area over any other spot.

    So, what would I recommend? As long as the MRI results seem to match up with your pain level, please be aggressive with treating the swelling for one month. Everyday do 5 things to reduce swelling, and after 30 days you have done 150 treatments for the swelling. The common treatments for swelling are:

    1. Contrast Bathing 1-2 times per day
http://www.drblakeshealingsole.com/2010/09/swelling-reduction-video-on-contrast.html

    2.  Ice Packs 10 minutes 3-4 times per day

http://www.drblakeshealingsole.com/2010/04/ice-or-cold-therapy-helps-in-injury.html

    3. Physical Therapy with topical cortisone called iontophoresis (5 times in a 2 week period)
    4. Elevation of the body part 2 hours per day (even if it is only several inches off the floor)
    5. 24/7 Compression with Tubigrip or Coban like wraps (physical therapists usually can guide you and perhaps even 1 PT visit to make sure you are wrapping correctly would be wise)

Here Coban is being used around a toe, but you will need to wrap it around the ball of the foot (all the way around the front of your foot).

   6.  Medicines like Zyflamend and topical anti-inflammatories (start with generic and see what the pharmacist recommends). Just stay away from the prescription anti-inflammatories like Advil and Aleve since they may slow down bone healing (and we are not 100% sure the bone is completely healed).

   7.  Of course, activity modification to avoid pain producing activities (over a level 2 or 3 pain) will reduce swelling by limiting aggravation. Read and understand the post on Good vs Bad Pain.

http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html

  8.  5 minutes of painfree massage to the swollen area

  9.  5 minutes of gentle motion of the toe with moving the toe up and down (active range of motion).

      Your doctor can also drain the joint (then they send the fluid to the laboratory for analysis). I have had a few patients develop a huge ganglion cyst after a sesamoid injury that needed to be drained like the one in the photo below.  The first photo is off the patient injured right foot. The second photo shows the difference in the non-involved side. The third photo shows the MRI of the swollen ganglion cyst that I have drained. Jeff, if you can take a similiar photo of the MRI image which shows the swelling the best, email it to me (even 2 or 3 images).

So, dedicate the next month at reducing the swelling. If the MRI shows the swelling this well organized, then you may need it drained. Let me know if this is helping you. Rich Blake

Top 100 Biomechanical Guidelines #43: Sagittal Plane Blockade may Occur with Everted not Inverted Heel Corrections (Forefoot Varus Correction could cause Blockade of Motion)

These are Forefoot Varus Casts. Uncorrected then lean inward and the arch would flatten and foot pronate. Correction of this foot has always been a dilemma for biomechanical experts. If you fully straighten this foot, the heel goes straight up and down, but the correction places too much support under the inside front of the foot (near the big toe). Drs Sheldon Langer, Justin Wernick, and Howard Dannenberg were the first podiatrists to discover and explore how potentially dangerous this support was. Too much pressure under the big toe area (first metatarsal) could block the normal motion of the foot from heel to toe and cause problems in the foot, ankle, knee, hip and back. They coined the phrase "Sagittal Plane Blockade" to describe this problem. When you walk with your orthotic devices, do you feel like you can easily move across them? This is a question I try to ask all my patients, and try to observe in gait evaluation. It is vital for normal foot function and to avoid symptoms.

     When I measure foot biomechanics, and I take a cast capturing over 5 degrees of forefoot varus, I know I will have issues for compromise to deal with. Fully correcting the total amount of forefoot varus would probably lead to problems related to Sagittal Plane Blockade. Correcting less than total could lead to the continuation of symptoms related to the pronation I was trying to treat in the first place. For the biomechanical experts out there, if you sacrifice some of the forefoot varus correction with a modified Root Balance Technique consider Kirby Skives, Inverted Pours, or BiAxial Wedging to get your pronation control without producing Sagittal Plane Blockade. You are basically transferring support from the front of the arch to the back of the arch.

drblakeshealingsole2's photostream

drblakeshealingsole2's photostream on Flickr.

I hope these photos can be quick reminders of solutions just forgotten in the mad rush of medicine. Dr Rich Blake

Custom Orthotic Devices and Shoe Inserts: They Do Not Coexist

When using a custom orthotic device, it is generally very important to remove the insert that comes with the shoe. Not only are there crowding issues, but the form of the shoe insert can effect the position of the orthotic device within the shoe. Thus, it can either help or hinder the orthotic device from doing it's job. The photo above illustrates this principle. My patient was complaining of 4th toe pain. When I looked at his shoe inserts you could see the 4th toe was overhanging the front edge, thus getting irritated. Had he bought the shoe too short? The solution was found at looking at how the orthotic devices were sitting in the shoe. The photo above shows the orthotic is being pushed forward by the heel cup of the shoe insert. If you push the orthotic forward, the whole foot will go forward, and the length of the toe will not be exact.

Here again you get a full view of the orthotic device sitting forward in the heel cup which would push the whole foot forward. To hedge my bet, I also taught the patient power lacing and gave some tongue pads to hold him back into the shoe heel counter better. I had him replace the shoe insert with a flat spenco insole.

    

drblakeshealingsole2's photostream

drblakeshealingsole2's photostream on Flickr.

Here is my first experiment with Flickr and my Blog. I will get better after I see how it works. Rich Blake

Plantar Fasciitis: When Surgery is Recommended, Have You Done All You Can Conservatively

http://www.lowerextremityreview.com/news/in-the-moment-foot-care/preferred-plantar-fasciitis-treatment-changes-with-duration-of-symptoms/comment-page-1#comment-1890

Plantar Fasciitis can be a frustrating injury for both the patients and treating practitioners alike. My blog has many posts on this subject for your review. The article above with my comment shows how many surgeries are done for this condition. Due to the vital nature of the plantar fascia, and its effect on foot function, surgery must be the last resort. The more I learn about plantar fasciitis, the more I realize it is rare that surgery is needed. So I get mad when I see quotes like that above discussing 73% of patients need surgery if they have had the symptoms over 10 monthes. It is quite distressing. Please spread the word that I believe surgery is needed for rare cases, and symptoms are helped the best when the practitioner throws away their treatment protocols and begins to think outside the box.

Typical area for the presentation of plantar fasciitis, which can spread under the heel, and into the arch.

Foot Protection While Sleeping (when in pain)

Emailed 4/1/11 from a foot pain sufferer from Seattle

Dear Dr Blake:
 One question I have found interesting is what to do about protecting my foot during sleep.  I have been doing many combinations of boot (awkward!), amateur taping (saw it in a textbook; quickly learned not to use athletic tape directly on the skin), ace bandage, flat sole shoe, etc etc and think I am doing OK now.

I can't thank you enough for your support, both in the blog itself, and in being willing to take your own time to write to people like me. It makes all the difference as I go forward!


Have a great weekend,

Ann
 
Ann, Thanks for the question. I know you are going to get well since you are working so hard at all the little but crucial details. Many of my patients, when their feet need protection while sleeping use the same splint that is used for plantar fasciitis and achilles tendinitis. See my link below on them. This posterior rest splint is very roomy and keeps your foot still and the sheets away from the sore areas. Hope this helps. Rich
 
http://www.drblakeshealingsole.com/2010/08/video-plantar-fasciitisachilles.html
 

Checking Changes in Heel Position With Orthotic Devices

Here is a simple video demonstrating the checking on heel position done with patients routinely. This is especially important with Corrective Orthotic Devices when you are trying to change someone who inverts too much to a vertical heel position, or someone who pronates too much to a more vertical heel position. Here the Inverted Orthotic Technique of 35 degrees changes the resting heel position from 12 degrees everted to 7 degrees everted. More orthotic correction therefore is needed to set the heel closer to vertical. A goniometer is used to measure the changes exactly.

Toe Nail Fungus Treatment with Dr Remedy's Nail Polish

I just recommended this to a patient. If you have toenail fungus, and you are doing the various treatments listed in the below posts, or even anti-fungal oral meds, here is a product that allows you to polish your toenails. Even if it helps 10% I am for it. But, as you may know, one of the very important aspects of toenail fungus treatment is getting oxygen to the nail beds. Toe nail polish will block the flow of oxygen, so use when you need to, and remove more often than you would otherwise.

http://www.remedynails.com/

Big Toe Joint Pain: Remedy for Dress Shoes

Margaret has right big toe joint pain. Her xrays which follow show slight peripheral bone irregularities classic for mild wear and tear arthritis. The pen points to the abnormal bone projections that can cause low grade pain and swelling in the joint on a chronic basis.

 Bone projection noted on top of the joint.

 Bone projection noted on the side of the joint closest to the second toe.

Bone projection noted on the outside border of the joint.

These subtle wear and tear changes can lead to low grade irritation which makes the joint fragile. That sensitivity means that the joint can get inflammed and painful easier than another joint.

When Margaret first came into the office the joint was so inflammed that physical therapy, icing, and spica taping was needed to cool it off. As she got back to normal activity, that sensitivity still made it impossible to wear fashionable shoes. After trying to have them stretched to no avail, she came back into the office today. Since the joint had great range of motion, and the pain seemed to be from pure pressure, 1/4 inch adhesive felt from http://www.mooremedical.com/ was used to off weight the sore area.

Margaret intentionally did not place her foot above all the way into the shoe so that the photo could capture the placement of the padding. Even though 1/4 felt was used the patient could add or subtract easily from the overall thickness. Felt is very easy thin out. The padding is never placed over the sore area, only next to it. Care would be taken in most cases to trim or place so that is not obvious to others.

Here was Margaret's email to me that afternoon (and she also got a medium gel toe separator to keep the big toe in alignment).


Hi Dr. Blake,
Got the X-ray...got the toe spacers. The toe spacers are great and I think they are helping in addition to the felt!

I am feeling much better!

Keep me posted on the X-ray.
Thank you so very much for your time!
Your are terrific!

Margaret
Sent from my Verizon Wireless BlackBerry

On Mar 30, 2011, at 6:02 PM, Richard Blake wrote:
Margaret, The xrays show very little arthritis on the joint, but enough to give you some chronic swelling. The toe seps and padding may be part of your wardrobe for awhile. Work on the swelling and see if you and I can make this happier. I will email when I put it on the blog. Rich



Hi Dr. Blake,


Thanks for the update on my X-ray. I do hope the terms "very little" stay "very little" and we can keep this arthritis from spreading.

I will continue to "do the right thing" and add the spacers, tape, and padding to my routine along with the ice massages.

In the meantime....if anything new comes up I will contact you.

Thanks again for your help.

Best,

Margaret











-






On Wed, Mar 30, 2011 at 11:27 AM, wrote:





Hi Dr. Blake,



Got the X-ray...got the toe spacers. The toe spacers are great and I think they are helping in addition to the felt!

I am feeling much better!

Keep me posted on the X-ray.

Thank you so very much for your time!

Your are terrific!

Margaret

Sent from my Verizon Wireless BlackBerry

Simple Shoe Modification for Supinators

The 2 photos below show a 1/4 inch wedge placed into the heel midsole to re-level a shoe that is beginning to break down due to over supination (the motion of spraining your ankle). This can be accomplished by a local shoe repair shop although bring in the photos. Many of my patients are in great shoes, but they just do not have enough stability in this area. This rolling out motion of the heel is also called lateral instability. The shoe wedge gives a strong resistance to that motion. If done correctly, you should never feel like you then roll your feet inward (the opposite motion of over pronation). You want to resist supination, but not become a pronator.